HIV, tuberculosis, and malaria: how can the impact of COVID-19 be minimised?

In The Lancet Global Health, Alexandra Hogan and colleagues¹ report the findings of a modelling study in which they estimate the number of excess deaths from HIV, tuberculosis, and malaria that could plausibly occur as a consequence of the COVID-19 pandemic. They conclude that, in high-burden settings, HIV, tuberculosis, and malaria deaths over a 5-year period could increase by 10%, 20%, and 36%, respectively, and that although the loss of life-years from this knock-on impact will probably be less than the direct impact of COVID-19, in high-burden countries, it could be of the same order of magnitude.

Any attempt at estimating the knock-on impact of a pandemic is fraught with difficulty, especially when so much remains unknown about the virus. In addition to the challenge of modelling the pandemic itself, and the potential impact of various intervention strategies, assessing the consequent impact on mortality caused by the other three diseases is hard. However, Hogan and colleagues take a well-structured path to derive their results, with four scenarios for how the COVID-19 pandemic might unfold, based on different policy responses and plausible assumptions about how these might affect the mortality dynamics of HIV, tuberculosis, and malaria. The aim of such modelling exercises is not so much to provide precise results, but to establish the scale of the impact, and to illuminate the most critical mechanisms that determine it.

The scale is daunting. In fact, based on other analyses from WHO,² UNAIDS,³ and the Stop TB Partnership,⁴ and our own real-life observations, the knock-on impact on HIV, tuberculosis, and malaria could potentially be even worse than this study suggests, and in some countries, it could be even worse than the direct impact of COVID-19. The Global Fund conducts a biweekly qualitative survey across the more than 100 countries in which it invests; the latest published results suggest that 85% of HIV, 78% of tuberculosis, and 73% of malaria programmes are being disrupted. 18% of HIV programmes, 17% of tuberculosis programmes, and 19% of malaria programmes are experiencing high or very high disruption.⁵

Hogan and colleagues highlight the primary drivers of increased mortality to be interruption of antiretroviral treatment for HIV, disruption of timely diagnosis and treatment of new cases for tuberculosis, and curtailment of mosquito net distribution for malaria. These factors are consistent with our own assessment. We are working with partners to ensure continuity of antiretroviral therapy and minimise exposure of people who are immunocompromised through home delivery, multi-month dispensing, and remote consultation. We are supporting initiatives to adapt and sustain tuberculosis case finding and treatment enrolment, including expanding laboratory capacity through procuring more molecular diagnostic instruments and training more technicians. We have assisted countries in adapting mosquito net distribution campaigns through buying motorcycles and protective equipment for volunteers so that nets can be distributed directly to households, rather than to village distribution points. Every week, we monitor the status of the 38 national mosquito net programmes scheduled for 2020. We also track delays and issues affecting supplies of essential commodities across all three diseases.

The Global Fund moved swiftly to support countries in responding to COVID-19. In early March, we introduced new flexibilities, allowing countries to redeploy savings and reprogramme up to 5% of existing grants. This made up to US$500 million immediately available. In April, we introduced the COVID-19 Response Mechanism, with an initial capacity of a further $500 million. As of July 7, 95 countries and eight regional programmes have used these schemes to invest $400 million. Initiatives funded include: treatment, condoms, and nutritional support to extremely vulnerable populations with HIV and tuberculosis, such as sex workers; personal protective equipment for community health workers; community-led communications and contact tracing; increased self-testing for HIV; and high throughput antigen diagnostic cartridges for COVID-19.

However, the $1 billion we have provided only mitigates a small part of the problem. In a report published in June, 2020,⁶ we argue that $28·5 billion is needed to fund an effective response to COVID-19 and prevent a potentially devasting impact on HIV, tuberculosis, and malaria in the highest-burden countries. Of this, the Global Fund could deploy $6 billion, or $5 billion in addition to the $1 billion we have already committed. As the multilateral institution created specifically to fight infectious disease pandemics, the Global Fund brings unique advantages to the fight against COVID-19. Moreover, no institution is better placed to manage the interdependencies with HIV, tuberculosis, and malaria, both ensuring we leverage the capabilities and infrastructure already in place and ensuring we minimise the knock-on impact.

In countries heavily affected by HIV, tuberculosis, and malaria, COVID-19 could result in many years of hard-won gains being reversed. We cannot let this happen. We need more resources and decisive action, and we must measure success not just in terms of minimising the direct impact of COVID-19, but in terms of minimising its total impact, including the knock-on impact on HIV, tuberculosis, and malaria.